F10B9400020 - FA2 Attachment T DPPO Self Funded



Contents TOC \o "1-3" \h \z \u FA2 Attachment T-1: Proposal Request PAGEREF _Toc532219055 \h 1FA2 Attachment T-2: Explanations and Deviations PAGEREF _Toc532219056 \h 5FA2 Attachment T-3: DPPO-SF Plan Design PAGEREF _Toc532219057 \h 6FA2 Attachment T-4: DPPO-SF Provider Network Access PAGEREF _Toc532219058 \h 8FA2 Attachment T-5: DPPO-SF Dental Providers PAGEREF _Toc532219059 \h 9FA2 Attachment T-6: DPPO - SF Compliance Checklist PAGEREF _Toc532219060 \h 12FA2 Attachment T-7: Questionnaire PAGEREF _Toc532219061 \h 24FA2 Attachment T-8a: Subcontractor Questionnaire PAGEREF _Toc532219062 \h 33FA2 Attachment T-8b: Subcontractor Questionnaire PAGEREF _Toc532219063 \h 35FA2 Attachment T-8c: Subcontractor Questionnaire PAGEREF _Toc532219064 \h 37FA2 Attachment T-8d: Subcontractor Questionnaire PAGEREF _Toc532219065 \h 39FA2 Attachment T-8e: Subcontractor Questionnaire PAGEREF _Toc532219066 \h 41FA2 Attachment T-8f: Subcontractor Questionnaire PAGEREF _Toc532219067 \h 43FA2 Attachment T-9: Performance Guarantees PAGEREF _Toc532219068 \h 45FUNCTIONAL AREA 2 – DPPO-SFFA2 ATTACHMENT T DPPO SELF FUNDED (SF) TECHNICAL PROPOSALFilename: FA2 Attachment T_10: DPPO-SF Technical Proposal (Part 2).docxFA2-Attachment T-10: DisruptionFA2 Attachment T-1: Proposal Request?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: The State of Maryland is requesting proposals for a Self-Funded dental PPO product (DPPO-SF) and a Fully-Insured Dental HMO product (DHMO). Please complete each item with the requested information for your proposed Self Funded DPPO plan. Items in the response column with the words "Choose an item" contain a drop down list of options. Please select a response from those options as applicable.I.GENERAL PLAN INFORMATION??Response1.Offeror's Legal NameClick here to enter text.?2.Plan NameClick here to enter text.?3.Proposed Plan TypeDPPO Self-Funded4.AddressClick here to enter text.5.CityClick here to enter text.6.StateClick here to enter text.7.ZipClick here to enter text.8.Web AddressClick here to enter text.?9.Operational DateClick here to enter a date.10.Corporate Tax StatusChoose an item.11.Federal Employer Identification NumberClick here to enter text.?12.Ownership/Controlling InterestClick here to enter text.?13.Year Network OrganizedClick here to enter text.?14.DPPO membership totals as of 1/1/2017Click here to enter text.??DPPO membership totals as of 1/1/2018Click here to enter text.15.Amount of professional liability insurance maintainedClick here to enter text.II.PLAN DESIGN????Offerors must adhere to the proposed plan designs shown in "FA2 Attachment T-3: DPPO-SF Plan Design" in preparing the quote.????Response1.Offerors agrees to adhere to the proposed plan designs shown in "FA1 Attachment T-3: DPPO-SF Plan Design" in preparing the quote and administering the DPPO Insurance benefits during the contract term.Choose2.Confirm that the proposal is issued in accordance with the specifications, assumptions and information included in this Request for Proposal, accompanying attachments and standard services addressed in the Information Questionnaire. If "No,” indicate deviations in "FA2 Attachment T-2: Explanation and Deviations."Choose3.Review and detail deviations from the proposed plan design shown "FA2 Attachment T-3: DPPO-SF Plan Design."ChooseIII.DENTAL DELIVERY SYSTEM??????Response?Complete the two (2) charts in "FA2 Attachment T-5: DPPO-SF Dental Providers.” For the counties shown, list the total number of participating providers by specialty. Also indicate the number of dentists accepting new patients, by specialty. For the states listed, provide the total number of participating providers.ChooseMembers’ Access to Providers?The State would like to determine the availability of key dental providers to its employee and retiree population. Please prepare GeoAccess? GeoNetworks? report(s) for the DPPO plan that you are proposing using census data provided by the State and the parameters in the table below. Provide the reports using two separate formats: 1. using current DPPO enrollment, and 2. using entire census population. Note that it is important that you follow the exact parameters. The report should show the availability by specialty for each zip code (or community). Report output is required for those with access and those without access, based upon the stipulated parameters. The report output should show the average distance to each provider group. See "FA2 Attachment T-4: Access" for the required format of the output. Hard copy reports need only contain the aggregated provider access information. In addition to the hard copy report, the data must be supplied in electronic format that has read/write capabilities (i.e. Microsoft Excel). Do not send the data in a read-only file. ?Use only physicians accepting new patients in your GeoAccess? GeoNetworks? provider file. The census you need to perform this mapping will be available via secure FTP upon execution of the confidentiality agreement (see Section 1.30). Label the completed GeoAccess? GeoNetworks? report as "Response FA2 Attachment T-1: GeoAccess GeoNetworks Report."?Practice Specialty?Number of Providers AvailableMiles from Employees Residence?General/Family dentists28?Specialists210?????????Select Response2.Has the GeoAccess? GeoNetworks? reporting been completed using the requested parameters?Choose an item.3.Please note the Geo-mapping method used:Choose an item.4.Was GeoAccess? GeoNetworks? Release 3.4.3, 2018 used to create the Accessibility Analysis?Choose an item.?????IV.ADMINISTRATIVE AND OPERATIONAL ISSUES??Other Services???1.List the location(s) of your service centers (separately identify claims processing centers and customer service centers if in different locations) that would be servicing the State's members and the corresponding geographic areas/regions covered by the respective location. Use "FA2 Attachment T-2: Explanations and Deviations" if you need more space.?Service Center Location(s)Geographic Region(s) Covered??Click here to enter text.Click here to enter text.??Click here to enter text.Click here to enter text.??Click here to enter text.Click here to enter text.??Click here to enter text.Click here to enter text.??Click here to enter text.Click here to enter text.????Response2.Please attach copies of your standard report suite, including monthly paid claims reports, which would be provided to the State at no additional cost. At a minimum, your package should include the report format for the reports requested in the Reporting Section of the Compliance Checklist. In addition, please provide the frequency of each of your standard reports. Label these reports "FA2 Attachment T-1: Management Reporting Package" in your proposal.Choose an item.3.Offeror has disclosed their claims appeals (claims decision or coverage) protocols as well as actual response time statistics for the most recent year. Label these reports "FA2 Attachment T-1: Claims Appeals Protocols" in your proposal.Choose an item.?????V.REFERENCES????Please complete the following tables with the requested reference information.?????1.Please provide three of your current employer client references of similar size (a minimum of 50,000 covered lives) offering DPPO services in the area that will be serving most of the State's employees. ?Information Reference #1Reference #2Reference #3?Company NameClick here to enter text.Click here to enter text.Click here to enter text.?Contact PersonClick here to enter text.Click here to enter text.Click here to enter text.?TitleClick here to enter text.Click here to enter text.Click here to enter text.?Telephone #Click here to enter text.Click here to enter text.Click here to enter text.?E-mail AddressClick here to enter text.Click here to enter text.Click here to enter text.?Network NameClick here to enter text.Click here to enter text.Click here to enter text.?# DPPO Members enrolledClick here to enter text.Click here to enter text.Click here to enter text.?Effective date of contractClick here to enter a date.Click here to enter a date.Click here to enter a date.?Description of services providedClick here to enter text.Click here to enter text.Click here to enter text.2.Please provide three of your terminated employer clients of similar size (a minimum of 50,000 covered lives) that offered DPPO services in the area that will be serving most of the State's employees. ?Information Reference #1Reference #2Reference #3?Company NameClick here to enter text.Click here to enter text.Click here to enter text.?Contact PersonClick here to enter text.Click here to enter text.Click here to enter text.?TitleClick here to enter text.Click here to enter text.Click here to enter text.?Telephone #Click here to enter text.Click here to enter text.Click here to enter text.?E-mail AddressClick here to enter text.Click here to enter text.Click here to enter text.?Network NameClick here to enter text.Click here to enter text.Click here to enter text.?# DPPO Members enrolled at date of terminationClick here to enter text.Click here to enter text.Click here to enter text.?Effective date of contractClick here to enter a date.Click here to enter a date.Click here to enter a date.?Termination date of contractClick here to enter a date.Click here to enter a date.Click here to enter a date.?Reason for termination?Click here to enter text.Click here to enter text.Click here to enter text.3.Please provide your three largest employer client references in the DPPO service area that will be serving most of the State's employees. ?Information Reference #1Reference #2Reference #3?Company NameClick here to enter text.Click here to enter text.Click here to enter text.?Contact PersonClick here to enter text.Click here to enter text.Click here to enter text.?TitleClick here to enter text.Click here to enter text.Click here to enter text.?Telephone #Click here to enter text.Click here to enter text.Click here to enter text.?E-mail AddressClick here to enter text.Click here to enter text.Click here to enter text.?Network NameClick here to enter text.Click here to enter text.Click here to enter text.?# DPPO Members enrolledClick here to enter text.Click here to enter text.Click here to enter text.?Effective date of contractClick here to enter a date.Click here to enter a date.Click here to enter a date.?Description of services providedClick here to enter text.Click here to enter text.Click here to enter text.VI.CONTACT INFORMATION???Primary contact of person authorized to execute this proposal?NameClick here to enter text.?TitleClick here to enter text.?AddressClick here to enter text.?CityClick here to enter text.?StateClick here to enter text.?Zip CodeClick here to enter text.?Telephone #Click here to enter text.?Cell Phone #Click here to enter text.?E-mail AddressClick here to enter text.FA2 Attachment T-2: Explanations and DeviationsRepresentations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: All deviations from the specifications of the Request for Proposal (RFP) must be clearly defined below Explanations must be numbered to correspond to the question number and section number to which it pertains. If additional space is required, submit a separate attachment labeled “FA2 Attachment T-2b: Explanations and Deviations” using the same table format. Most importantly, keep all explanations brief. In the absence of any identified deviations, your organization will be bound to the terms of the RFP.???Section # / Question #Indicate "Explanation" or "Deviation"Offeror ResponseClick hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Click hereChoose Click here to enter text.Please indicate if FA2 Attachment T-2b: Explanations and Deviations is provided. Choose an item.FA2 Attachment T-3: DPPO-SF Plan Design Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Any deviations between the State's current plan design and the proposed plan design of the Offeror must be noted in the space provided below. If there are no deviations in the Offeror's proposed plan design, please enter the phrase "No Deviations" in the space provided.Service TypeCurrent DPPO PlanDeviations from Current DPPO PlanClass I(Preventive)100%Click here to enter text.Class II (Basic Restorative Services)70%Click here to enter text.Class III(Major Services)50%Click here to enter text.Class IV(Orthodontia – Child Only)50%Click here to enter text.Annual Deductible* $50 per Plan Year Deductible per person (excluding Class I & Orthodontics) not to exceed $150 per familyClick here to enter text.Annual Maximum$2500 per Plan Year maximum per personClick here to enter text.Orthodontia Lifetime Maximum $2000 Lifetime maximum per person for OrthodonticsClick here to enter text.* Applies only to Class II and III services.Class I – Preventive services including, but not limited to:ExamsAll X-RaysCleanings & Fluoride TreatmentsPalliative Treatment (Emergency)SealantsClass II – Basic Restorative services including, but not limited to:EndodonticSurgical PeriodonticsOral Surgery ServicesSpace MaintainersGeneral AnesthesiaBasic Restorative (Filings, etc.)Non-surgical PeriodonticsRepairs of Crowns, Inlays, OnlaysRepairs of BridgesDenture RepairSimple ExtractionsSurgical PeriodonticsComplex Oral Surgery??Class III – Major Restorative services including, but not limited to:Inlays, Onlays, CrownsProsthetics (Bridges, Dentures) ??Class IV – OrthodontiaDiagnostic, Active, Retention TreatmentLimited to dependent children under the age of 26FA2 Attachment T-4: DPPO-SF Provider Network AccessInstructions: Provide the following access information for each type of in-network provider listed in the access request (General/Family dentists, Endodontists, Oral Surgeons, Prosthodontists, Pedodontists, Periodontists, Orthodontists, and Other Specialist Dentists). Provide access two ways: 1) all employees and retirees currently enrolled in the DPPO and 2) all employees and retirees (entire census population). (Please note that the total number of employees/retirees excludes those employees/retirees located in Guam, Puerto Rico, Virgin Islands, countries other than the United States and APO addresses.)??A.All employees and retirees currently enrolled in DPPO????Provider TypeAccess CriteriaAverage Distance to ProvidersTotal Number of Employees / RetireesEmployees MatchedEmployees Not Matched?NumberPercentNumberPercent?General/Family Dentist2 in 8Click here?97,500Click here?Click hereClick hereClick here?Endodontists2 in 10Click here?97,500Click here?Click hereClick hereClick here?Oral Surgeon2 in 10Click here?97,500Click here?Click hereClick hereClick here?Prosthodontist2 in 10Click here?97,500Click here?Click hereClick hereClick here?Pedodontist2 in 10Click here?97,500Click here?Click hereClick hereClick here?Periodontist2 in 10Click here?97,500Click here?Click hereClick hereClick here?Orthodontist2 in 10Click here?97,500Click here?Click hereClick hereClick here?Other Specialist Dentist2 in 10Click here?97,500Click here?Click hereClick hereClick here?????????B.All employees and retirees?????Provider TypeAccess CriteriaAverage Distance to ProvidersTotal Number of Employees / RetireesEmployees MatchedEmployees Not Matched?NumberPercentNumberPercent?General/Family Dentist2 in 8Click here119,000Click hereClick hereClick hereClick here?Endodontists2 in 10Click here119,000Click hereClick hereClick hereClick here?Oral Surgeon2 in 10Click here119,000Click hereClick hereClick hereClick here?Prosthodontist2 in 10Click here119,000Click hereClick hereClick hereClick here?Pedodontist2 in 10Click here119,000Click hereClick hereClick hereClick here?Periodontist2 in 10Click here119,000Click hereClick hereClick hereClick here?Orthodontist2 in 10Click here?119,000Click here?Click hereClick here?Click here?Other Specialist Dentist2 in 10Click here?119,000Click here?Click hereClick here?Click hereFA2 Attachment T-5: DPPO-SF Dental ProvidersRepresentations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: For the counties shown below, list the total number of participating in-network providers by specialty. Also indicate the number of providers accepting new patients, by specialty. County/Metro AreaCategoryGeneral/ Family DentistOrthodontistPedodontistProstho-dontistPeriodontistOral SurgeonEndodontistTotal Dental ProvidersCentral MarylandAnne Arundel County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereBaltimore City# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereBaltimore County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereCarroll County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereHarford County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereHoward County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereEastern ShoreCaroline County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereCecil County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereDorchester County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereKent County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereQueen Anne's County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereSomerset County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereTalbot County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereWicomico County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereWorcester County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereSouthern MarylandCalvert County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereCharles County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereSt. Mary's County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereWashington MetroDistrict of Columbia# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereMontgomery County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick herePrince George's County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereWestern MarylandAllegany County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereFrederick County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereGarrett County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereWashington County# of providersClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick here# accepting new patientsClick hereClick hereClick hereClick hereClick hereClick hereClick hereClick hereInstructions: For the states and locations shown below, list the total number of participating providers by specialty.StateGeneral DentistOrthodontistPedodontistProsthodontistPeriodontistOral SurgeonEndodontistAlabamaClick hereClick hereClick hereClick hereClick hereClick hereClick hereAlaska Click hereClick hereClick hereClick hereClick hereClick hereClick hereArizonaClick hereClick hereClick hereClick hereClick hereClick hereClick hereArkansasClick hereClick hereClick hereClick hereClick hereClick hereClick hereCaliforniaClick hereClick hereClick hereClick hereClick hereClick hereClick hereColoradoClick hereClick hereClick hereClick hereClick hereClick hereClick hereConnecticutClick hereClick hereClick hereClick hereClick hereClick hereClick hereDelawareClick hereClick hereClick hereClick hereClick hereClick hereClick hereDistrict of ColumbiaClick hereClick hereClick hereClick hereClick hereClick hereClick hereFloridaClick hereClick hereClick hereClick hereClick hereClick hereClick hereGeorgiaClick hereClick hereClick hereClick hereClick hereClick hereClick hereHawaiiClick hereClick hereClick hereClick hereClick hereClick hereClick hereIdahoClick hereClick hereClick hereClick hereClick hereClick hereClick hereIllinoisClick hereClick hereClick hereClick hereClick hereClick hereClick hereIndianaClick hereClick hereClick hereClick hereClick hereClick hereClick hereIowaClick hereClick hereClick hereClick hereClick hereClick hereClick hereKansasClick hereClick hereClick hereClick hereClick hereClick hereClick hereKentuckyClick hereClick hereClick hereClick hereClick hereClick hereClick hereLouisianaClick hereClick hereClick hereClick hereClick hereClick hereClick hereMaineClick hereClick hereClick hereClick hereClick hereClick hereClick hereMassachusettsClick hereClick hereClick hereClick hereClick hereClick hereClick hereMichiganClick hereClick hereClick hereClick hereClick hereClick hereClick hereMinnesotaClick hereClick hereClick hereClick hereClick hereClick hereClick hereMississippiClick hereClick hereClick hereClick hereClick hereClick hereClick hereMissouriClick hereClick hereClick hereClick hereClick hereClick hereClick hereMontanaClick hereClick hereClick hereClick hereClick hereClick hereClick hereNebraskaClick hereClick hereClick hereClick hereClick hereClick hereClick hereNevadaClick hereClick hereClick hereClick hereClick hereClick hereClick hereNew HampshireClick hereClick hereClick hereClick hereClick hereClick hereClick hereNew JerseyClick hereClick hereClick hereClick hereClick hereClick hereClick hereNew MexicoClick hereClick hereClick hereClick hereClick hereClick hereClick hereNew YorkClick hereClick hereClick hereClick hereClick hereClick hereClick hereNorth CarolinaClick hereClick hereClick hereClick hereClick hereClick hereClick hereNorth DakotaClick hereClick hereClick hereClick hereClick hereClick hereClick hereOhioClick hereClick hereClick hereClick hereClick hereClick hereClick hereOklahomaClick hereClick hereClick hereClick hereClick hereClick hereClick hereOregonClick hereClick hereClick hereClick hereClick hereClick hereClick herePennsylvaniaClick hereClick hereClick hereClick hereClick hereClick hereClick hereRhode IslandClick hereClick hereClick hereClick hereClick hereClick hereClick hereSouth CarolinaClick hereClick hereClick hereClick hereClick hereClick hereClick hereSouth DakotaClick hereClick hereClick hereClick hereClick hereClick hereClick hereTennesseeClick hereClick hereClick hereClick hereClick hereClick hereClick hereTexasClick hereClick hereClick hereClick hereClick hereClick hereClick hereUtahClick hereClick hereClick hereClick hereClick hereClick hereClick hereVermontClick hereClick hereClick hereClick hereClick hereClick hereClick hereVirginiaClick hereClick hereClick hereClick hereClick hereClick hereClick hereWashingtonClick hereClick hereClick hereClick hereClick hereClick hereClick hereWest VirginiaClick hereClick hereClick hereClick hereClick hereClick hereClick hereWisconsinClick hereClick hereClick hereClick hereClick hereClick hereClick hereWyomingClick hereClick hereClick hereClick hereClick hereClick hereClick hereTotalClick hereClick hereClick hereClick hereClick hereClick hereClick hereFA2 Attachment T-6: DPPO - SF Compliance Checklist?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. Instructions: Please complete each item with the requested information. Items in the response column with the words "Choose an item,” contain a drop down list of options. Please select a response from those options as applicable. All "No" responses must be addressed in "FA2 Attachment T-2: Explanations and Deviations.”?Compliance ChecklistOfferor's ResponseYes or NoCustomer ServiceOfferor agrees to permit all eligible Members, as determined by the State, to obtain dental benefits for themselves and their Dependents.ChooseOfferor agrees to no loss/no gain provision: All members and dependents covered under the prior plan as of December 31, 2019, will be covered as of January 1, 2020.ChooseOfferor agrees to establish and provide a dedicated, state-of-the-art customer service operation (including a toll-free line) that is available to plan Participants (both in-state and out-of state) 24 hours a day, seven days a week, staffed by live customer service representatives.ChooseThis toll-free customer service line will be supported by an automated voice-response system 24 hours a day, seven days a week. Participants (both in-state and out-of state) can access this system directly to request and receive service authorizations or other pertinent data. This operation should be in accordance with PG-1 and PG-2 on "FA1 Attachment T-9: Performance Guarantees.”ChooseDuring call center hours, as indicated above, the customer service phone intake system should be an automatic answering system that picks up within 30 seconds and directs Participants into a queue to be serviced, with an available opt-out to a live representative at any time during the call.ChooseAutomated call answer system will provide estimated wait time until live operator pick-up to Participant.ChooseClaim forms (if used) must be mailed to Participants within two business days from the date of request. ChooseThe member services and provider relations operations must include:a.) Knowledgeable staff available to answer questions on plan eligibility, plan guidelines, benefit levels, and claims procedures. Chooseb.) The ability to access an eligibility file that identifies eligible Participants as well as certain other pertinent information regarding Participants. Choosec.) A system for providing Explanations Of Benefits to eligible Participants detailing payments to providers for services rendered and the amounts applicable to each service.Choosed.) A procedure for handling emergency requests or non-office hour services.Choosee.) An integrated claims and customer service system enabling both claims and service team members to view all screens.Choosef.) Adequate access to the customer service system for individuals with disabilities. (TTY and online access for deaf, full-service phone access for blind)ChooseOfferor agrees to establish on-line web access for members to securely look up plan information, participating providers, claim status and history of processed claims.ChooseOfferor agrees to accurately convert State data files, which are transmitted in HIPAA 834 format. This includes the State master enrollment file and any other relevant files to the Offeror's data system.ChooseOfferor agrees to offer support services during the Open Enrollment period preceding the initial plan year of the contract and all subsequent open enrollments during the contract term. Offeror will provide services in accordance with PG-3 on "FA2 Attachment T-9: Performance Guarantees.”ChooseOfferor will provide representatives to attend Benefit Fairs, who will be trained on the State-specific benefit plans, in accordance with PG-3 on "FA2 Attachment T-9: Performance Guarantees.”ChooseOfferor agrees to assume a share of the expenses for printing and mailing the State of Maryland Open Enrollment booklet and universal enrollment forms, cost for which will be shared equally among all benefit plans. For 2018 Open Enrollment, each State vendor's share was approximately $19,800 per plan.ChooseOfferor shall prepare and provide identification cards and a detailed plan description to Members. ID cards are to be mailed to members at least ten business days before the program is operational. ID cards must be mailed to new members within three business days of notification by the State or receipt of the add/change/delete enrollment file that reflects the new enrollment, whichever is earlier. The detailed plan description will be provided electronically (and via paper upon request). ChooseOfferor will use a unique identification number (that is not a social security number) on all Participant communications, including, but not limited to, membership cards, EOBs, etc.ChooseEvidence of Coverage is available to members both via US Mail and online. Evidence of Coverage shall be mailed within 30 days from the date of enrollment.ChooseUpon request, Offeror will submit forms for the State's approval, and print forms with the State's logo for claims submission.ChooseNetwork Compliance/ReimbursementOfferor agrees to provide Participant support services for selecting and/or locating network providers, including but not limited to contacting providers to ensure that they are still in the network when requested by a Member and answering provider credential questions that Participants may have. ChooseOfferor agrees to provide on-line access to up-to-date network provider listings and locations to assist Participants with provider selection as well as assist with other Participant services with regard to provider selection.ChooseOfferor agrees to notify plan Participants, in writing with at least 45 days advance notice, in the event that the contract for a Participant's network provider terminates for any reason. The State will review and approve the communications provided to State Participants for this purpose.ChooseOfferor agrees to notify the State, in writing with at least 60 days advance notice, in the event that the contract for a dentist terminates for any reason.ChooseOfferor has a procedure in place to allow the State and/or plan Participants to nominate providers to be considered for inclusion in the network panel, and if included, made available to Participants.ChooseOfferor agrees to notify the State immediately if the Offeror loses any licenses, certificate of insurance, liability insurance coverage or certificate of authority from the Maryland Insurance Administration or any other state insurance department.ChooseOfferor commits that all provider contracts for its network have a "continuation of care" clause that says if for any reason a provider’s contract is terminated, including but not limited to if a provider cancels or fails to renew their contract, a course of treatment which began with a network provider will continue to be provided and reimbursed by that provider at the contract rate previously in effect.ChooseOfferor will track Reasonable and Customary (R&C) and claim payment data by most current CDT code and zip code.ChooseOfferor agrees to make changes to CDT codes on dental procedures and nomenclature when updated by the American Dental Association. Offeror further agrees to confirm these changes, in writing to the State, no later than 90 days after the effective date of the changes.ChooseOfferor agrees that all services included in the State's benefit program will be covered at the same benefit level regardless of CDT procedure code changes.ChooseOfferor has and will maintain a Pre-Determination process for Participants to contact customer service to find out the maximum allowance for a specific procedure in advance of having the procedure done. ChooseOfferor confirms that procedures are in place for ensuring that a network provider does not bill participants and/or the plan sponsor any amount in excess of the network allowance.ChooseOfferor's contracts with network providers prohibit providers from balance billing patients above the network allowance.ChooseOfferor will guarantee that a Participant will not be liable for any amounts over and above the scheduled plan benefit in the event a network provider is not paid accurately for services rendered.ChooseOfferor will guarantee that the network allowance will always be the basis for determining the member's liability (coinsurance, etc.), if applicable, for in-network services rendered.ChooseAudits ?The Offeror agrees to have an annual audit performed by an independent audit firm of its handling of the Department’s critical functions and/or sensitive information, which is identified as Insurance Claims Processing Services (collectively referred to as the “Information Functions and/or Processes”). Such audits shall be performed in accordance with audit guidance: Reporting on Controls at a Service Organization Relevant to Security, Availability, Processing Integrity, Confidentiality, or Privacy (SOC 2) as published by the American Institute of Certified Public Accountants (AICPA) and as updated from time to time, or according to the most current audit guidance promulgated by the AICPA or similarly-recognized professional organization, as agreed to by the Department, to assess the security of outsourced client functions or data (collectively, the “Guidance”)ChooseOfferor agrees to provide the State or its designated representative the right to audit the performance of the plan and services provided (including quality of care and HIPAA compliance). Offeror will make available all services, records and access to the auditors at no extra charge. Offeror will be given 2 months written advance notice of an impending audit. The State or its designated representative will audit operations at least once annually.ChooseHIPAA ?(Terms herein shall have meaning provided in 45 CFR, Parts 160, 162 and 164.) The Contractor agrees to comply with HIPAA security regulations, 45 CFR Part 164, subpart C.ChooseThe Contractor agrees to comply with HIPAA privacy standards, 45 CFR Parts 160 and 164.ChooseThe Contractor shall comply with 45 CFR 164.508(a)(4) and §13405(d)(1) and (2) of the HITECH Act as if it were a covered entity in connection with the benefits plan administered by the Contractor pursuant to this RFP and Contract. The Contractor shall prohibit its business associates, agents and subcontractors who receive, use, disclose, create, retain, maintain, or transmit PHI from receiving remuneration in exchange for PHI on the same terms.ChooseThe Contractor shall comply with the limitations on marketing and fundraising communications provided in 45 CFR 164.508(a)(3) and §13406 of the HITECH Act as if it were a covered entity in connection with the benefits plan.ChooseData Breach Responsibilitiesa.) A breach shall be treated as discovered in the terms described in 45 CFR §164.410.Chooseb.) Notice to the Department(1) The Business Associate shall promptly notify the Department of a breach of unsecured PHI in its possession following the first day on which the Contractor (or Contractor's employee, officer, agent or subcontractor) knows of such breach or following the first day on which Contractor (or Contractor's employee, officer, agent or subcontractor) should have known of such breach. Such notice shall occur without unreasonable delay and in no event more than 30 days following discovery of the breach. Such notice shall occur even if the breach is not of a Member of the State's Plan.Choose(2) In the event that Contractor determines that there is no risk of an unauthorized access, acquisition, use, or disclosure compromises the security or privacy of the PHI of a Participant, Contractor shall promptly notify the Department of the event and the basis for that determination. Such notice shall occur as soon as is reasonable but in no event more than 30 days following discovery of the unauthorized access, acquisition, use or disclosure of PHI of a Participant. Such determination shall be in writing and signed by an appropriate officer or employee of Contractor.Choose(3) Contractor's notice to the Department pursuant to this section concerning breaches shall include, at a minimum:(i) the number of individuals overall affected by the breach and the number of Participants in the State's Plan affected by the breach;Choose(ii) if applicable, the identification of each State Plan Participant whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used, disclosed, or otherwise the subject of the breach;Choose(iii) a description of what happened, the date of the breach, if known, and the date of the discovery of the breach;Choose(iv) a brief description of the types of unsecured PHI that were involved in the breach (such as name, social security number, date of birth, claims or health care services information, etc.);Choose(v) identification of an individual who can provide additional information concerning the breach; andChoose(vi) a brief description of the steps Contractor is taking to mitigate the breach, investigate the breach, and to protect against further breaches.Choose(4) Contractor's notice to the Department pursuant to this section may be provided on a rolling basis, with information provided to the Department as it becomes available.Choosec.) Notice to Participants.(1) Business Associate shall provide notice to affected members and to the media in the form, content, manner, method, and timing required to meet the requirements of §§13400-13402 of the HI TECH Act and 45 CFR §§164.404 and 164.406, applied as if Business Associate were a covered entity in connection with the group plan(s) administered by Business Associate pursuant to the Underlying Agreement.Choose(2) The notice(s) required by this section may not be issued until the Department has reviewed and approved the notice(s). Such approval may not be unreasonably delayed or withheld.Choosed.) Contractor may delay the notice(s) required pursuant to sections 164.404(b) and 164.406(b) only if permitted pursuant to 45 CFR §164.412.Choosee.) In the event of an unauthorized use or disclosure of PHI or a breach of Unsecured PHI, Contractor shall use reasonable efforts to mitigate any harmful effects of said disclosure that are known to it.Choosef.) Notices to DHHS.(1) In the event of a breach described in 45 CFR §164.408(b), Contractor shall provide to Department all information required by that subsection to be submitted to the Secretary of DHHS. The information shall be provided without unreasonable delay and in no event more than 30 days following discovery of the breach. Upon request, Contractor shall submit the required breach notice to the Secretary of DHHS on behalf of the Department, the State, the group plan(s), and the Program.Choose(2) Contractor shall maintain a log of breaches described in 45 CFR §164.408(c) and that affect members and the group plan(s) administered by Business Associate pursuant to the Underlying Agreement.Chooseg.) In fulfilling its obligations pursuant under this Contract in connection with 45 CFR §164.530, Business Associate shall address the provisions of 45 CFR Part 164, subpart D in the manner provided in 45 CFR §164.414, as if Contractor were a covered entity in connection with the benefits plan administered by the Contractor pursuant to this Contract and RFP.Chooseh.) Business Associate agrees to review any guidance from DHHS specifying the technologies and methodologies that render PHI unusable, unreadable, or indecipherable to unauthorized individuals. BA further agrees, to the extent practical, appropriate and reasonable, to incorporate such guidance into its administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of PHI.Choosei.) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides PHI received from, or created or received by the Contractor, agrees to provide notice of a breach and the information necessary for the Contractor to comply with its notice requirements in sections (a) through (h) above.ChooseElectronic Health Recordsa.) Contractor shall notify the Department if and when Contractor uses or maintains electronic health record(s) with respect to PHI.Chooseb.) As of the applicable effective date identified in HITECH §13405(c )(4), when complying with the obligations to respond to requests for an accounting under 45 CFR §164.528, Contractor shall respond to requests for an accounting of disclosures of PHI, in compliance with the requirements of §13405( c)(1) and (3) of the HITECH Act and any regulations promulgated by the Secretary of DHHS pursuant to §13405( c)(2) of the HITECH Act. The requirements of this section shall apply if Contractor uses or maintains an electronic health record with respect to PHI.Choosec.) When complying with the obligation to provide access to PHI under 45 CFR §164.524, Contractor shall respond to requests for access to PHI in compliance with the requirements of §13405(e) of the HITECH Act. The requirements of this section shall apply if Contractor uses or maintains an electronic health record with respect to PHI.ChooseThe Contractor agrees to provide all HIPAA certificates of creditable coverage, at no extra cost, within the timeframe required by the regulations (see 45 CFR §146.115).ChooseThe Contractor confirms that its proposal, and plan design offered, is in compliance with all federal and state laws and regulations that pertain to employee benefit plans.ChooseThe Contractor understands, has the necessary systems capability and complies with HIPAA's administrative simplification standards related to electronic data interchange (EDI), including the code set/transactions requests of 45 CFR Part 162.ChooseThe Contractor requires any agents/subcontractors it brings onto the project(s) covered by this RFP to comply with the HIPAA standards for EDI.ChooseSpecial ProvisionsOfferor will provide at least 6 months’ notice to the State of Maryland for any planned systems upgrades or changes (to include claims, customer service, eligibility, corporate operating system). ChooseOfferor agrees to retain records in excess of the period required by the Contract, if required by State and Federal regulations for group dental plans.ChooseOfferor agrees that there will be no restrictions or benefit limitations for pre-existing conditions applied to any eligible Participants under the plan.ChooseOfferor agrees to prepare and file all legal documents necessary to implement and maintain the plan, including policies, amendments, contracts, required state filings, and development of booklet/certificate formats.ChooseOfferor agrees to monitor federal and state legislation affecting the delivery of dental benefits under the plan and to report to the State on those issues in a timely fashion prior to the effective date of any mandated benefit changes.ChooseOfferor will absorb the cost of programming any benefit design changes.ChooseMember service operations must include an information system capable of electronically transmitting, receiving, and updating Participant profile information regarding demographics, coverage, and other information (e.g. eligibility, change of address, etc.).ChooseOfferor agrees to have a process in place for resolving complaints operable on the date of contract commencement. The State expects an expeditious, written resolution will normally be mailed within 10 workdays of receipt of the complaint. ChooseClaim ProcessingOfferor agrees that all claims will be paid in accordance with the benefit program described in "FA2 Attachment T-3: DPPO-SF Plan Design" in this Request for Proposal.ChooseOfferor agrees to use the NAIC 120-1 Model COB Contract Provisions, as excerpted in Attachment Q of the RFP, for determining when to pay as primary coverage.ChooseNotwithstanding anything in the attachments to the contrary, Offeror agrees to administer the plan to provide Coordination of Benefits (COB) under a “pay and pursue” basis with other employee, retiree, and/or dependent dental coverage.ChooseOfferor will verify and update Participant records with information on other coverage at least annually and more frequently if notified by the State or Participants. ChooseOfferor agrees to use its R&C profiles, reduced network fees, or those of the primary carrier in determining its level of reimbursement when it is the secondary payor in a COB situation.ChooseTo the extent permitted under state law, no fault auto insurance, governmental plans (Medicaid) coordination and negligent third party subrogation will be included in the contract.ChooseOfferor certifies that it is able to and will administer the dental plans in compliance with all State laws, regulations and mandates.ChooseOfferor certifies that it will comply with the Department of Labor's final claims procedure regulations, including:a) The notice requirements for improper and incomplete claimsChooseb) The appropriate timeframes for adjudicating urgent, pre-service and post-service claimsChoosec) The appropriate timeframes for notice of appeal decisions.Choosed) Offeror will agree to exhaust this appeals process prior to turning it over to the State of Maryland. ChooseOfferor agrees to provide written updates to State of changes in claims appeal process.ChooseThe claims system maintains on-line eligibility files that are updated at least weekly.ChooseOfferor agrees to claims fiduciary responsibilities, including appeals, for claims adjudication and defense of "utilization review" decisions.ChooseNetwork members never have to submit claim forms for in-network services.ChooseEach of your networks serving State members is supported by a computerized, on-line direct access claims processing system containing plan/claim information storage and retrieval.ChooseOfferor will obtain the advice and consultation of qualified experts (internal or external, as needed) to review unusual charges or claims at no additional cost to the State. ChooseOfferor will review claims history for benefits issued during retroactive and in eligible periods and initiate overpayment recovery efforts.ChooseOfferor agrees to provide claims adjudication at 90th R&C percentile for non-network DPPO services. ChooseOfferor agrees to provide EOB's by mail for both in-network and out-of-network services.ChooseOfferor agrees to process 99% of claims dollars accurately and provide to the State evidence of such processing during quarterly vendor meetings.ChooseOfferor agrees to process 97% of claims accurately and provide to the State evidence of such processing during quarterly vendor meetings.ChooseReporting Offeror agrees to deliver the required management information reporting in the format specified by the State that provides utilization, claims reporting, and administrative services data by subgroup to the State of Maryland. The required subgroups are: State Actives, State Retirees, Direct Pay, Satellite Account, and in Total. See CC-78 through CC-90 for data elements and format for each report.ChooseThe State requires a number of regular quarterly and annual claim reports. The Offeror will provide these reports in an electronic format upon data availability following the end of the accounting period to both the State and the State's benefit consultant. ChooseOfferor agrees to provide separate reports for each Functional Area, including performance guarantee reports.ChooseOfferor shall supply, on a monthly basis, a full file of all claim activity to the State's data warehouse vendor. This file shall include unique identification number and member Social Security Number. This file shall be transmitted electronically to a designated VPN connection.ChooseQuarterly reports include:A report showing paid claims by month, service category, number of enrolled employees/retirees, number of enrolled participants (including employees/retirees and their dependents) for the following groups: (1) In and Out-of-Network. (2) State employees, Direct Pay, Satellites, Retirees, and in Total. (3) The paid claim service categories are: Class I (Preventive), Class II (Basic/Restorative), Class III (Major) and Class IV (Orthodontia). This report shall be due on the same schedule described in PG-11 in "FA2 Attachment T-9: Performance Guarantees.”ChooseOfferor must self-report on each of the Performance Guarantee measurements as defined in the Quarterly Plan Performance Measurement Report Card to the State on a calendar quarter basis, in the format requested. See PG-11 in "FA2 Attachment T-9: Performance Guarantees."ChooseThe data elements shown on “Attachment U-1a: Utilization and Cost Schedule, -1b: Membership Analysis, and U-1c: DPPO Network Utilization” must be reported on a calendar quarter basis, in the format requested. See PG-12 in "FA2 Attachment T-9: 'Performance Guarantees."ChooseA network summary report showing number of providers with a change in network status, including additions, terminations and those dentists no longer accepting new patients. This report should separate data based on plan and specialty type.ChooseA report describing network development activities for the previous quarter and a network development plan for the upcoming quarter.ChooseA report including the number and dollar value of outstanding overpayments.ChooseAnnual reports include:A rate renewal report, as required by PG-14 on "FA2 Attachment T-9: Performance Guarantees,” including, but not limited to:?a.) Projection of incurred and paid claim costs for renewal year;Choose?b.) Complete documentation of the methodology and assumptions used to develop the projected costs, including a break out of all expenses;Choose?c.) Disclosure of supporting data used in calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc.;Choosed.) Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees;Choosee.) Explanations for any unusual trend results (high/low relative to the market).ChooseA report summarizing the outcomes of the Offeror's Quality Management initiatives (as detailed in the Quality Assurance section below) for the prior plan year and areas of focus for the upcoming plan year.ChooseOther reporting requirements include:For the DPPO, Offeror will track and report accumulation toward calendar maximum and lifetime orthodontia maximum by Participant for reporting to State on a quarterly basis and to Participant at certain accumulation milestones, as determined by the State. ChooseOfferor will provide Ad Hoc reporting flexibility to accommodate up to 15 requests annually, at no additional charge.ChooseImplementation ScheduleOfferor agrees to comply with the implementation schedule as described in the RFP Section 2.2.3, Project Implementation Milestones and Due DatesChoosePayment Specifications Offeror agrees to accept premium payments in accordance with the dental payment procedures described in RFP Section 3.3, Payment Terms.ChooseOfferor agrees to accept payment processed through normal State transmittal process (i.e., transmittal sent to Annapolis, EFT transfer to Offeror.) (See Section 4.31 Non-Disclosure Agreement of the RFP document.)ChooseOfferor agrees that the only compensation to be received by or on behalf of its organization in connection with this Plan shall be that which is paid directly by the State. ChooseAccount Management/Customer ServiceUpon request by the State, the Offeror agrees to change the designated account manager, claim supervisor, claim processor and/or claim facility for any reason at any time.ChooseOfferor will provide a dedicated (but not exclusive) account management team for the State.ChooseOfferor will provide a succession plan upon request for the account management team.ChooseOfferor will provide a dedicated (but not exclusive) customer service team for the State that is separate from the claim processing unit.ChooseOfferor will provide a designated senior eligibility contact for the State.ChooseOfferor will provide a designated senior underwriting contact for the State.ChooseOfferor will provide a designated senior premium payment contact for the State.ChooseOfferor will provide a designated senior reporting contact for the State.Offeror will provide a designated senior claims/customer service contact for the State.ChooseOfferor will provide a designated senior billing contact for the State.ChooseOfferor will provide a dedicated (but not exclusive) claim processing unit for the State.ChooseOfferor will provide complete contact information for the contacts indicated in items CC-96 through CC-102 above.ChooseOfferor will attend quarterly meetings to discuss plan administration and any other concerns the State may have. Meetings will be set with the State in advance on a designated day each quarter. Meeting reporting content will include but not be limited to financial performance, performance guarantee results, customer services issues and process improvement, Offeror will attend meetings in accordance with PG-3 on "FA2 Attachment T-9: Performance Guarantees.”ChooseOfferor agrees to review two drafts each year of the plan description contained in the State's Open Enrollment booklet each year, upon request by the State, and at no extra cost.ChooseOfferor agrees to meet or exceed established performance standards as described in "FA2 Attachment T-9: Performance Guarantees.” ChooseProvider Contracting/ RelationsOfferor provides routine education to network providers regarding the plan's policies and procedures through a manual, periodic newsletters, and special meetings, as needed.ChooseOfferor agrees to develop and adhere to a detailed network development plan based on the State's needs and agreed to by the State.ChooseOfferor agrees to perform annual visits to all network providers. ChooseOfferor agrees to provide upon request by State a periodic “at-risk” provider report at no additional cost to the State.ChooseThe Contractor(s) agrees to the Payment Terms for Both Services Categories as described in Section 3.3.1ChooseThe Contractor(s) agrees to the Responsibilities and Tasks as described in Section 2.3.ChooseThe Contractor(s) agrees to the Contract Initiation Requirements as defined in Section 3.1ChooseThe Contractor(s) agrees to the End of Contract Transition as defined in Section?3.2ChooseThe Contractor(s) agrees to the Invoicing as defined in Section 3.3ChooseThe Contractor(s) agrees to the Liquidated Damages as defined in Section 3.4ChooseThe Contractor(s) agrees to the Disaster Recovery and Data as defined in Section 3.5ChooseThe Contractor(s) agrees to the Insurance Requirements as defined in Section?3.6ChooseThe Contractor(s) agrees to the Security Requirements as defined in Section?3.7ChooseThe Contractor(s) agrees to the Problem Escalation Procedure as defined in Section 3.8ChooseThe Contractor(s) agrees to the SOC 2 Type 2 Audit Report as defined in Section 3.9ChooseThe Contractor(s) agrees to the Experience and Personnel as defined in Section 3.10ChooseThe Contractor(s) agrees to the Substitution of Personnel as defined in Section 3.11ChooseThe Contractor(s) agrees to the Minority Business Enterprise (MBE) Reports as defined in Section 3.12ChooseThe Contractor(s) agrees to the Veteran Small Business Enterprise (VSBE) Reports as defined in Section 3.13ChooseThe Contractor(s) agrees to the No-Cost Extensions as defined in Section 3.14ChooseREMINDER: All "No" responses must be addressed in "FA2 Attachment T-2: Explanations and Deviations.”FA2 Attachment T-7: QuestionnaireRepresentations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please provide a response to each of the following questions. Items in the response column with the words "Choose an item,” contain a drop down list of options. Please select a response from those options as applicable. NOTE: All "No" responses must be addressed in "FA2 Attachment T2: Explanations and Deviations." QuestionOfferor's ResponseGENERALBriefly describe your company's experience in providing DPPO Self Funded dental benefits.Click here to enter text.How long he you offered DPPO Self Funded dental plans to Maryland based clients? Provide a separate answer for each plan type quoted.Click here to enter text.Is your organization compliant with all applicable HIPAA administrative simplification rules?Choose an item.a.) Will your organization be involved in any acquisitions or mergers within the next 12 months?Choose an item.If yes, please describe.Click here to enter text.b) Has your organization been involved in any recent acquisitions or mergers?Choose an item.● Within the last 12 months?Choose an item.● 1-2 years ago?Choose an item.● 2-5 years ago?Choose an item.● None in the last five yearsChoose an item.If yes, please describe.Click here to enter text.Confirm that your organization has Errors and Omissions Insurance and Commercial General Liability Insurance.Please submit a copy of your certificate(s) of insurance indicating coverage limits and label as "Response FA2 Attachment T-7: Certificates of Insurance.”● E & OChoose an item.● Commercial General LiabilityChoose an item.Provide the following aggregate claims information for 2016 and 2017:Calendar Year 2016● Total claim dollars paid under all dental plans administered or insuredClick here to enter text.● Total claim dollars paid under all DPPO plans administered or insuredClick here to enter text.● Total members covered under all dental plans administered or insuredClick here to enter text.● Total members covered under all DPPO plans administered or insuredClick here to enter text.● Total claim dollars paid under dental plans administered or insured in the State of MarylandClick here to enter text.● Total claim dollars paid under DPPO plans administered or insured in the State of MarylandClick here to enter text.● Total members covered under all dental plans administered or insured in the State of MarylandClick here to enter text.● Total members covered under all DPPO plans administered or insured in the State of MarylandClick here to enter text.Calendar Year 2017● Total claim dollars paid under all dental plans administered or insuredClick here to enter text.● Total claim dollars paid under all DPPO plans administered or insuredClick here to enter text.● Total members covered under all dental plans administered or insuredClick here to enter text.● Total members covered under all DPPO plans administered or insuredClick here to enter text.● Total claim dollars paid under dental plans administered or insured in the State of MarylandClick here to enter text.● Total claim dollars paid under DPPO plans administered or insured in the State of MarylandClick here to enter text.● Total members covered under all dental plans administered or insured in the State of MarylandClick here to enter text.● Total members covered under all DPPO plans administered or insured in the State of MarylandClick here to enter text.On average, by what percentage have premiums for the DPPO plan proposed increased over the last three years?For your proposed network for the State of Maryland, what percentage of participating providers in your proposed network were not accepting new patients during the following calendar years?Calendar Year 2016● General/Family dentistsClick here to enter text.● OrthodontistsClick here to enter text.● PedodontistClick here to enter text.● PeriodontistClick here to enter text.● Oral SurgeonClick here to enter text.● EndodontistClick here to enter text.Calendar Year 2017● General/Family dentistsClick here to enter text.● OrthodontistsClick here to enter text.● PedodontistClick here to enter text.● PeriodontistClick here to enter text.● Oral SurgeonClick here to enter text.● EndodontistClick here to enter text.Does your provider directory (both on-line and hardcopy) indicate the following information for each network provider?● Handicap accessibleChoose an item.● Multi-lingualChoose an item.● Distance from member locationChoose an item.● If accepting new patientsChoose an item.● SpecialtyChoose an item.Are you anticipating any material changes (+/- 5%) in network size (for either general/family dentists or specialists) in the network area serving State of Maryland employees and retirees during the next 12 months?Choose an WORK MANAGEMENTWho conducts the provider credentialing process? Please indicate the qualifications of the person(s) or organization(s) responsible for conducting this review.Click here to enter text.Are onsite visits conducted during the credentialing process?Choose an item.How are Specialty dentists re-credentialed? How often?Click here to enter text.Do you conduct provider satisfaction surveys?Choose an item.If yes, please provide a copy of the results of your latest survey.Please submit response and label as "Response FA2 Attachment T-7: Provider Satisfaction Survey.”If yes, what percentage of providers are satisfied with your plan?Click here to enter text.List the top five most common complaints by your network providers:● #1 ComplaintClick here to enter text.● #2 ComplaintClick here to enter text.● #3 ComplaintClick here to enter text.● #4 ComplaintClick here to enter text.● #5 ComplaintClick here to enter text.Are general/family dentists at any financial risk for specialty services? Choose an item.If so, please explain.Click here to enter text.Please describe your experience providing narrow and / or high-quality networks and current networks that are available to plan sponsors. How do you determine providers in these networks?Click here to enter text.Has your organization implemented any unique network arrangements or plan designs in the past 5 years?Choose an item.If so, please explain.Click here to enter text.What is your annual dental turnover rate for the following?Calendar Year 2016● # of dentists joining the planClick here to enter text.● General/Family dentistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.● SpecialistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.Calendar Year 2017● # of dentists joining the planClick here to enter text.● General/Family dentistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.● SpecialistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.Calendar Year 2018 (YTD)● # of dentists joining the planClick here to enter text.● General/Family dentistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.● SpecialistsVoluntarily terminatedClick here to enter text.Non-voluntarily terminatedClick here to enter text.How do you monitor judicial or regulatory restrictions imposed on your providers? Explain your process for identifying, monitoring and terminating problem providers.Click here to enter text.How often do you pay providers? Describe the payment process(es); identify separately processes for each provider type quoted, if it differs.Click here to enter text.Does your organization perform provider profiling or other quality measures to identify providers with patterns of over/under treatment to members?Choose an item.If yes, give examples.Click here to enter text.Please provide responses to the following items that apply when an individual provider or group practice notifies your plan of an intent to terminate participation in your network:● Describe what actions are taken by your plan to retain the individual provider or group practice in the network.Click here to enter text.● Describe what actions are taken to recruit individual providers or another group practice for the network in place of terminated providers.Click here to enter text.● Describe what notices are sent to members concerning termination of their provider. Click here to enter text.● Provide a copy of a sample member letter concerning provider termination.Please provide a copy "Response FA2 Attachment T-7: Sample Member Letter-Provider Termination.”Please describe your plan's defined program and process to systematically evaluate participating General Dentists for cost, utilization, clinical outcomes, administration cooperation and member services satisfaction.Click here to enter text.Describe the specific measures used by your organization in the development of your networks and to monitor dentist access.Click here to enter text.Describe your policy for dealing with patients who complain that they cannot be seen by a participating provider as soon as they desire. How do you handle patients who cannot wait for the next available appointment?Click here to enter text.Under what circumstances and how are dependents covered outside of your service area?Choose an item.CARE MANAGEMENTDescribe the staffing, qualifications, training programs and monitoring for your Utilization Review (UR) staff.Click here to enter text.How are dental emergencies (both in and out of area) and accidental dental services provided?Click here to enter text.QUALITY OF CAREDescribe any quality improvement initiatives, including results, undertaken in the last 12 months.Click here to enter text.Describe any capabilities or Programs in place to increase utilization of preventive services.Click here to enter text.Describe specific examples of how your quality assurance program has led to improved care in the following areas:● Monitoring adherence to treatment guidelines and protocols.Click here to enter text.● Ongoing maintenance and evaluation of the quality and appropriateness of care.Click here to enter text.● Utilization management.Click here to enter text.● Reviewing and approving credentials of patient care professionals.Click here to enter text.● Clinical aspects of risk management.Click here to enter text.● Infection control.Click here to enter text.● Facility quality (i.e., appointment timeliness, location, cleanliness, parking, etc.)Click here to enter text.● Formal committee that sets quality assurance policy and reviews outcomes on a regular basis.Click here to enter text.SYSTEMSAre there any electronic system changes planned for the contract term?Choose an item.If yes, please describe.Click here to enter text.Does your system track referrals to specialists or non-contracted providers?Choose an item.If yes, please describe.Click here to enter text.Is there a contingency plan(s), procedure, and system in place to provide backup service in the event of strike, natural disaster or backlog?Choose an item.If yes, please describe.Click here to enter text.How often are the systems backup and disaster recovery systems tested?Click here to enter text.When were the systems last tested and what were the results?Click here to enter text.What system down time have you experienced during the most recent 12 months?Click here to enter text.How long are records maintained?Click here to enter text.How quickly can the State's services be reinstated in the event of permanent disaster to both the hardware and software?Click here to enter text.CLAIMS ADMINISTRATIONProvide the following information regarding your Dental Director:● NameClick here to enter text.● SpecialtyClick here to enter text.● The current percentage of time as Dental Director versus private practiceClick here to enter text.● Number of years as Dental DirectorClick here to enter text.● Number of years in private practiceClick here to enter text.● If not currently practicing dentistry, indicate the last year in private practice.Click here to enter text.● Provide resume for the Dental DirectorPlease submit resume and label as "Response FA2 Attachment T-7: Dental Director Resume.”How many claims processors will be assigned to handle the State's account?Click here to enter text.Do customer service representatives (CSRs) have authority to approve claims?Choose an item.What access do CSRs have to the dental director?Click here to enter text.Describe the initial and ongoing training programs for the claim administration team (e.g. claim processors, supervisors and other management staff).Click here to enter text.What is the average amount of time Claims staff spends in annual ongoing training?Click here to enter text.Please note the source of your R&C information (e.g. HIAA, MDR, internally developed, other).Click here to enter text.List the locations of all claims offices that you propose to process claims for the State.Click here to enter text.What is the most recent annual turnover rate for your claims processing staff in your proposed location(s)?Click here to enter text.For each of the claims offices that will service the State, what were the claims financial accuracy rates during 2017 and 2018 (YTD)?Click here to enter text.For each of the claims offices that will service the State, what were the claims procedural error rates during 2017 and 2018 (YTD)?Click here to enter text.For each of the claims offices that will service the State, what are the target claim error rates?● % financial accuracyClick here to enter text.● % procedural accuracyClick here to enter text.For each of the claims offices that will service the State, what are the average and target turnaround times for clean claims?● Calendar daysClick here to enter text.● Current Average %Click here to enter text.● Target %Click here to enter text.Describe the claims payment process from date of receipt to full adjudication of checks to providers or patients.Click here to enter text.When and under what circumstances are claims pended?Click here to enter text.Does a pending notice go into the system?Click here to enter text.Is there an automatic follow-up?Choose an item.What is the frequency of the follow-up?Click here to enter text.How many follow-ups are performed?Click here to enter text.Describe your administrative requirements with respect to claims filed directly by members.Click here to enter text.Provide your claims processing standards for claim adjudication financial accuracy versus actual for 2018 (YTD).Click here to enter text.Provide your claims timeliness standards for claim adjudication versus actual for 2018 (YTD).Click here to enter text.What percent of claims are automatically adjudicated?Click here to enter text.Describe your Ad Hoc reporting capabilities.Click here to enter text.What is the suggested pre-determination of benefits threshold amount?Click here to enter text.How is this communicated to participants and providers?Click here to enter text.MEMBER SERVICESDescribe the member services unit that will be assigned to the State.● StructureClick here to enter text.● Number of representativesClick here to enter text.● QualificationsClick here to enter text.● Average years of experienceClick here to enter text.● Toll-free contact numberClick here to enter text.● Hours of operationClick here to enter text.● Type of unitChoose an item.What is the most recent annual turnover rate of the member services unit that will be assigned to the State?Click here to enter text.Please describe the training of a member service representative.Click here to enter text.What percentage of your member services representatives speak the following languages:● EnglishClick here to enter text.● SpanishClick here to enter text.● Other (please specify)Click here to enter text.What is the average speed to answer in seconds?Click here to enter text.What is the percent call abandonment rate?Click here to enter text.What percentage of member calls are recorded?Click here to enter text.Identify which of the following functions are automatically tracked and reported by the system. Note that the State requires these data on a quarterly basis. Select all that apply.● Call abandonment rateChoose an item.● Length of callChoose an item.● Number of calls takenChoose an item.● On-line call recordingChoose an item.● Speed of call responseChoose an item.● Type of call/complaintChoose an item.Does your system utilize an Interactive Voice Response (IVR) system?Choose an item.Do you have a correspondence tracking system to log in, assign and track correspondence?Choose an item.Describe your procedure for referrals to providers outside the network.Click here to enter text.How long are referrals valid?Click here to enter text.What assistance do you provide plan members if a network provider terminates his or her contract during the plan year?Click here to enter text.How and when are members notified of the termination?Click here to enter text.What happens to patients who had been receiving ongoing treatment from a former network provider?Click here to enter text.Describe your formal member grievance process, including time frames from the initial receipt of a grievance until resolution.Click here to enter text.Describe your grievance tracking system.Click here to enter text.WEB BASED SERVICESDescribe your web-based capabilities.Click here to enter text.Have you implemented, or do you plan to implement within the next 12 months, an Internet or other electronic connection for the following? Describe all that apply.● Enrollment administrationClick here to enter text.● Eligibility administrationClick here to enter text.● ReportingClick here to enter text.● Employer access to real time claim statusClick here to enter text.● EOB Look UpClick here to enter text.● Other (please explain)Click here to enter text.Have you implemented, or do you plan to implement within the next 12 months, an Internet or other electronic connection that will be available to members for the following? Describe all that apply.● Access member servicesClick here to enter text.● Access a provider selection databaseClick here to enter text.● Make claim inquiriesClick here to enter text.● Access other information (please specify)Click here to enter text.● Download member identification cardClick here to enter text.Please provide the website address for the provider directory.Click here to enter text.Provide its password, if necessary.Click here to enter text.Is provider information, in addition to contact information, available to members via the internet?Choose an item.If yes, please describe.Click here to enter text.IMPLEMENTATION PROGRAM / TRANSITIONPlease discuss your procedures and processes for handling the employee communications regarding the change in plans during the initial vendor transition period.Click here to enter text.Implementation Plan● Please provide the Name of the person with overall responsibility for planning, supervising and implementing the program for the State.Click here to enter text.● Please provide the Title of the person named above.Click here to enter text.● What other duties, if any, will this person have during implementation? Please include the number and size of other accounts for which this person will be responsible during the same time period.Click here to enter text.● What percentage of this person's time will be devoted to the State during the implementation process?Click here to enter text.● Please provide an organizational chart identifying the names, functions and reporting relationships of key people directly responsible for implementing the State of Maryland account.Please submit organization chart and label as "Response FA2 Attachment T-7: Implementation Team Organizational Chart.”● Provide a detailed implementation plan that clearly demonstrates the Offeror's ability to meet the State's requirements to have a fully functioning program in place and operable on January 1, 2020. This implementation plan should include a list of specific implementation tasks/transition protocols and a time-table for initiation and completion of such tasks, beginning with the contract award and continuing through the effective date of operation (January 1, 2020). The implementation plan should be specific about requirements for information transfer as well as any services or assistance required from the State during implementation. The implementation plan should also specifically identify those individuals, by area of expertise, responsible for key implementation activities and clearly identify their roles. A detailed organizational chart as well as resumes should be included.Please submit the Offeror's description of account management support and label as "Response FA2 Attachment T-7: Implementation Plan.”Do you anticipate any major transition issues during implementation?Choose an item.If yes, please describe.Click here to enter text.Account Management Plan● Please provide the Name of the person with overall responsibility for planning, supervising and performing account services for the State.Click here to enter text.● Please provide the Title of the person named above.Click here to enter text.● What other duties, if any, does this person have? Please include the number and size of other accounts for which this person is responsible.Click here to enter text.● What percentage of this person's time will be devoted to the State?Click here to enter text.● Please provide an organizational chart identifying the names, functions and reporting relationships of key people directly responsible for account support services to the State. It should also document how many account executives and group services representatives will work full-time on the State's account and how many will work part-time on the State's account.Please submit organization chart and label as "Response FA2 Attachment T-7: Account Management Team Organizational Chart.”● Describe account management support, including the mechanisms and processes in place to allow State personnel to communicate with account service representatives, hours of operation; types of inquiries that can be handled by account service representatives; and a brief explanation of information available on-line. The State requires identification of an account services manager to respond to inquiries and problems, and a description of how the Offeror's customer service and other support staff will respond to subscriber or client inquiries and problems. The management plan should include the names, resumes and description of functions and responsibilities for all supervisors and managers that will provide services to the State with respect to this contract.Please submit the Offeror's description of account management support and label as "Response FA2 Attachment T-7: Account Management Support.”The State of Maryland would like direct access to the Offeror's eligibility systems for review and input purposes. Please describe your ability to provide the State with direct access to the eligibility system only.Click here to enter text.Are you able to receive eligibility data via the Internet?Choose an item.Is eligibility processing real-time with the claim system?Choose an item.If no, what is the delay time?Choose an item.Briefly describe how your organization will process the HIPAA 834 file layout internally (convert to proprietary file specification, dump to paper, etc.)Click here to enter text.Briefly describe your process for correcting data in the event of a data tape which contains "bad data.”Click here to enter text.Provide a complete listing of all services which are subcontracted and the subcontractor used. (Please complete "FA2 Attachment T-8 Subcontractor Questionnaire" for each of the subcontractors listed here.)Click here to enter text.Are all subcontractors compliant with all applicable HIPAA administrative simplification rules?Choose an item.What procedures do you have in place to ensure subcontractor compliance?Click here to enter text.REMINDER: All "No" responses must be addressed in "FA2 Attachment T-2: Explanations and Deviations.”FA2 Attachment T-8a: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-8b: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-8c: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-8d: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-8e: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-8f: Subcontractor Questionnaire?Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.Instructions: Please complete one "FA2 Attachment T-8: Subcontractors Questionnaire" for each subcontractor that the Offeror proposes to have perform any of the required functions under this contract. Clearly indicate if a proposed subcontractor is an MBE certified by the State of Maryland, if responding for a MBE subcontractor.?Subcontractor's Name (if applicable)?Click here to enter text.Subcontractor's MDOT Number (if applicable)?Click here to enter text.QuestionOfferor's ResponseSQ-1Provide a brief summary of the history of the subcontractor's company and information about the growth of the organization on a national level and within the State of Maryland.Click here to enter text.SQ-2Specifically what roles will the subcontractor have in the performance of the Contract?Click here to enter text.SQ-3Explain the process for monitoring the performance of the subcontractor and measuring the quality of their results.Click here to enter text.?List any services for which the subcontractor will be solely responsible and describe how the subcontractor will be monitored and managed.Click here to enter text.SQ-4Provide the following information about the subcontractor's company:??● Organization's legal nameClick here to enter text.?● State of incorporationClick here to enter text.?● Date of incorporationClick here to enter text.?● Insurance certification from the Maryland Insurance AdministrationClick here to enter text.SQ-5Describe any significant government action or litigation taken or pending against the subcontractor's company or any entities of the subcontractor's company during the most recent five (5) years.Click here to enter text.SQ-6Provide the addresses, including city and state, for the subcontractor's following activities:??● Corporate/ Firm Management OfficeClick here to enter text.?● Customer Service OfficeClick here to enter text.?● Provider Service OfficeClick here to enter text.?● Account Management/ Client Services OfficeClick here to enter text.?● Technical Support OfficeClick here to enter text.SQ-7Does the subcontractor have contractual relationships with third party administrators/ organizations in which the subcontractor pays service fees or other fees that you (the Offeror) are directly or indirectly charged for? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.Click here to enter text.SQ-8What fidelity and surety insurance, general liability and errors and omissions or bond coverage does the subcontractor carry to protect its clients? Describe the type and amount of each coverage that would protect this plan. Please furnish a copy of all such policies for review.Click here to enter text.FA2 Attachment T-9: Performance GuaranteesRepresentations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.?Offeror will report results on all performance measurements quarterly per the requirements of the Report Card and separately for each plan type. Performance results will also be audited annually by the State's contract auditor.Note: It is critical to the success of the State's programs that services be maintained in accordance with the schedules agreed upon by the State. It is also critical to the success of the State's programs that the Contractor operates in an extremely reliable manner. It would be impracticable and extremely difficult to fix the actual damage sustained by the State in the event of delays or failures in claims administration, service, reporting, and attendance of Contractor personnel on scheduled work and provision of services to the citizens of the State. The State and the Contractor, therefore, presume that in the event of certain delay(s) or failure(s), the amount of damage which will be sustained from the delay or failure will be the amount set forth below, and the Contractor agrees that in the event of any such failure of performance, the Contractor shall pay such amount as liquidated damages and not as a penalty. The State, at its option for amount due the State as liquidated damages, may deduct such from any money payable to the Contractor or may bill the Contractor as a separate item. NOTE: Items in the response column with the words "Willing to Comply” contain a drop down list of options including Yes or No. Please select a response from those options as applicable. All "No" responses must be addressed in "FA2 Attachment T-2: Explanations and Deviations.”?Performance IndicatorStandard/GoalReporting Measurement (subject to audit by State and/or contract auditors)Liquidated Damages*Willing to ComplyTelephone Call AvailabilityMeasurements must be State-specific or for only the service center handling the State account.Average speed of answer by a live service representative (with knowledge of State of Maryland account) is 30 seconds or less. The representative must be able to address the member's issue/question. Time over which standard is measured: Quarter Plan Performance Measurement Report Card and supporting data (to be submitted by the Vendor).Frequency of report: Quarterly$1,500 for each second over 30.ChooseTelephone Call Abandonment RateMeasurements must be State-specific or for only the service center handling the State account.Abandonment rate of less than 3%.Time over which standard is measured: QuarterReport Card and supporting data (to be submitted by the Vendor).Frequency of report: Quarterly$500 per percentage point over 3% per reporting periodChooseContractor attendance at State-sponsored annual Open Enrollment meetings and orientation meetingsAttendance by plan representative(s) trained on State of Maryland plan benefits at 100% of meetings scheduled by the State, for 100% of the meeting’s duration. Representative must arrive early enough to have their table set up prior to meeting start time. Display must be organized and include appropriate covering of table. Representative must have detailed plan knowledge, interact with members, and exhibit professional appearance and behavior.Sign-in sheets at Open Enrollment meetings Frequency of report: Annually$500 per scheduled meeting not attendedChoose Complaint Resolution TimePlan will:a) acknowledge receipt of the written complaint to the State and Member within two business days of receipt of the complaint letter; andb) provide a written complaint response to the State and Member within 21 business days of receipt of the initial complaint letterSelf Reported and State correspondence logs$250 for each late acknowledgement letter and$250 for each late written complaint response.Choose Provision of Draft Plan Documents Certificate/Evidence of Coverage of Self-Insured plans and Summary Plan Description for the fully-insured plansDraft Plan Document (Certificate/Evidence of Coverage or Summary Plan Description as appropriate by plan) including all required updates is provided to the State at least three months prior to the first day of the plan year. For example, if the plan year effective date is January 1st, the vendor must provide the State the draft by October 1st of the prior year.Receipt date as documented by vendor and confirmed by State$500 per day for the first three calendar days that the draft document is not received.$1,000 per calendar day for each day the draft document is not received for the fourth calendar day and beyondChoose Provision of Final Plan DocumentsFinal Plan Document (Certificate/Evidence of Coverage or Summary Plan Description as appropriate by plan) including all of the required edits and in the format ready for posting to State intranet is returned to the State no later than 45 days before the start of the plan year within 30 calendar days of the carrier’s receipt of the State’s edits.Receipt date as documented by vendor and confirmed by State$500 per day for each calendar day the draft plan document is not received for the first 3 calendar days.$1000 per day for each day the draft plan document is not received for the fourth calendar day and beyondChooseImplementationAll administrative functions completed for a Successful Open Enrollment and program implementation as of the effective date of the contract. Overall rating of 4.5 or greater on a scale of 1 to 5 must be received. One time measurement after the first quarter of the initial plan year by State of Maryland DBM staff using implementation evaluation$15,000. Payment due within 30 days of invoice.ChooseTimeliness of processing of Enrollment Eligibility Update InformationPlan will process tape or electronic interchange of State enrollment information by 7:00 AM of the second business day after receipt. If tape is received after 12 noon, record will reflect it as having been received as of the next business day.Time over which standard is measured: QuarterReport Card - Vendor to maintain log and system generated reports for review by the State's contract auditor. Frequency of report: Quarterly$3,000 for each calendar day, or portion thereof, of delay. ChooseAccuracy of Processing Enrollment Eligibility InformationPlan will process electronic interchange of State enrollment with at least 98% accuracy.Time over which standard is measured: QuarterReport Card - Vendor to maintain log and system generated reports for review by the State's contract auditor.Frequency of report: Quarterly$3,000 for each percentage point, or fraction thereof, under 98%.ChooseAccount ManagementPlan representatives will return all messages received from DBM (whether voice mail, e-mail or other communication method) promptly. Messages received before 12 Noon will be replied to the same day. Messages received after 12 Noon will be replied to by 12 Noon of the following business day.Time over which standard is measured: QuarterReport Card - Vendor to maintain log for review by the State's contract auditor. Frequency of report: Quarterly$150 for each delayed response.ChooseDelivery of Quarterly Plan Performance Measurement Report Card to the StateDelivery to the State by 6:00 pm on the following dates**:Date-stamp of receipt by the State.Frequency of report: Quarterly$3,000 for each week, or fraction thereof that Report Card is not received.ChooseFirst Quarter (Jan –Mar)Due: May 1stSecond Quarter (Apr – Jun)Due: August 1stThird Quarter (Jul – Sep)Due: November 1stFourth Quarter (Oct – Dec)Due: February 1stDelivery of Quarterly Utilization and Case Management Data Reports to the State and the State's Consultant (see Attachment U)Delivery to the State by 6:00 pm on the following dates**:Documentation of receipt by State's Benefit Consultant, i.e., date-stamp of mailing package for data information and verification of completeness. (All required fields must be filled in correctly.)Frequency of report: Quarterly$3,000 for each week, or fraction thereof, the data report is not received or is incomplete.ChooseFirst Quarter (Jan – Mar)Due: May 1stSecond Quarter (Apr – Jun)Due: August 1stThird Quarter (Jul – Sep)Due: November 1stFourth Quarter (Oct – Dec)Due: February 1stDelivery of Rate Renewal ReportsDelivery to the State and to the State's actuarial consultant of reports required for annual rate renewal process by 6:00 PM May 31st of each contract year for the next contract year. At a minimum, the renewal reports must include (but not be limited to) the following**:Date-stamp of receipt by the State and verification of completeness of required documentation.Frequency of report: Annually$3,000 for each week, or fraction thereof, that the rate renewal reports are not received or are incomplete.Choose● projection of incurred claim costs for renewal yearChoose● estimate of IBNR reserves at end of current year; including the most recent 36 months of incurred/paid triangular reportsChoose● complete documentation of the methodology and assumptions utilized to develop the projected costsChoose● disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc.Choose● substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those feesChoose● explanations for any unusual trend results (high relative to the market, low relative to the market)ChooseProvider TurnoverA turnover rate of less than 5% annually will be maintained for both the general dentist and specialty network. Calculation should include all terminations regardless of reason for termination.Quarterly vendor report$50,000 if turnover is greater than 5%, $100,000 if greater than 7%.ChooseNetwork AccessUrban: 2 open locations within 8 miles = 99%.Time over which standard is measured: QuarterQuarterly vendor report$50,000 if not met.ChooseSuburban: 2 open locations within 8 miles = 95%.Time over which standard is measured: QuarterQuarterly vendor report$50,000 if not met.ChooseRural: 2 open locations within 8 miles = 60%Time over which standard is measured: QuarterQuarterly vendor report$50,000 if not met.ChooseEmployee Satisfaction A 90% or higher member satisfaction rate. Time over which standard is measured: AnnualSurvey results of the State’s annual Customer Satisfaction Survey.Frequency of report: Annually $15,000 if performance is less than standards.ChooseMember call resolution85% of member calls resolved on first call.Time over which standard is measured: QuarterQuarterly vendor report including phone and customer service system reporting.$15,000 if performance is less than the standard.ChooseClaims Standard-Financial Accuracy99% of claim dollars processed accurately.Measured by the State's independent auditor as part of the annual claims audit. Measured to two (2) decimal places.Measures the gross dollars paid incorrectly (overpayments plus underpayments) subtracted from total paid claim dollars, divided by total paid claim dollars within the audit sample. $25,000 if between 97% - 98.99%, $50,000 if less than 97%.ChooseClaims Standards: Payment Accuracy 97% of claims w/ benefit payments are processed accurately.Measures the number of incorrect drafts of payments made on behalf of the State, subtracted from the total draft or payment transactions, divided by the total draft or payment transactions as measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places.$25,000 if below 97% but at least 95%.$50,000 if less than 95%.Choose an item.Claims Standards: Processing Time95% of all claims are adjudicated within 10 business days; and 98% of all claims are adjudicated within 20 business days. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places.$500 per period in which standard is not met.Choose an item.* Determination of results and any applicable damages will be conducted by the State's contract auditor and be based on actual administrative fees included in the total premium rates.** If due date falls on a state / vendor holiday or a weekend, Report Card and reports are due next business day.REMINDER: All "No" responses must be addressed in “FA2 Attachment T-2: Explanations and Deviations.” ................
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